Ultrasonographic findings and natural history of intraductal papillary-mucinous neoplasms of the pancreas

It is clear that the prevalence of malignancy is high in the main-duct type of intraductal papillary-mucinous neoplasm (IPMN). Branch-duct IPMNs include several histologic conditions such as carcinoma, adenoma, and hyperplasia. Intraductal papillary adenocarcinoma and papillary adenoma are characterized by papillary protrusions and thick septum-like structures in dilated ducts as delineated by ultrasonography. A solid mass showing a mixedecho pattern in the pancreatic parenchyma is a characteristic finding of invasive types of IPMN. The international guidelines for the management of branch-duct IPMNs suggest that the appearance of symptoms attributable to the cyst, the presence of intramural nodules, a cyst size greater than 30 mm, and dilation of the main pancreatic duct (>6 mm) are indications for resection. Based on the relationship between the height of a papillary protrusion and the diameter of a cystic dilated branch as well as on histological findings, branch-duct IPMNs with papillary protrusions more than 10 mm in height as shown by imaging should be resected, and it is not adequate to differentiate carcinoma from other lesions based on the diameter of cystic branches alone. A follow-up study on branch-duct IPMNs revealed that most papillary protrusions showed a slow increase in size or development of lateral spread, and that there was no development of cancer with stromal invasion during an average follow-up of 46 months. Therefore, the presence of intramural nodules alone should not be an indication for surgery. Also, patients without papillary protrusions or thick septum-like structures are not immediate candidates for surgery. Invasive adenocarcinoma can develop at a pancreatic site different from the area of interest showing cystic changes, with such invasion possibly being multicentric. Therefore, in patients with branch-duct IPMNs, attention should be paid to the entire pancreas when performing follow-up examinations.     

胰腺导管内乳头状黏液性肿瘤的影像学诊断进展

胰腺导管内乳头状黏液性肿瘤是一种位于扩张的主胰管和(或)分支胰管内、伴大量黏液分泌的肿瘤,易与慢性胰腺炎或胰腺囊腺瘤混淆而延误诊断.本文就国内外近年来关于胰腺导管内乳头状黏液性肿瘤的临床病理学及影像学研究进展进行综述,评价不同影像技术(US、CT、MRCP、ERCP)在胰腺导管内乳头状黏液性肿瘤诊断中的作用.     

胰腺导管内乳头状黏液性肿瘤的MSCT和MRCP诊断

目的 探讨胰腺导管内乳头状黏液性肿瘤 （IPMN）的MSCT和MRCP影像学表现.方法 对26例经内镜或手术病理证实的IPMT患者的CT和MRCP表现进行回顾性分析.结果 分支胰管型IPMN12 例,表现为单发囊性病变或葡萄串样多发囊性病变伴腔内分隔或结节样突起;主胰管型 IPMN 5 例,表现为主胰管扩张伴管壁结节样突起;混合型IPMN 9例,表现为主胰管扩张和囊性病变合并存在.9例手术病理结果为腺瘤1例,交界性肿瘤2例,腺癌6例.结论 MSCT和MRCP对发现和诊断胰腺 IPMN具有较高价值.     

胰腺导管内乳头状黏液性肿瘤的多层螺旋CT诊断

目的探讨胰腺导管内乳头状黏液性肿瘤在多层螺旋CT上的影像特点。方法回顾性分析30例经手术切除和病理学证实的胰腺导管内乳头状黏液性肿瘤的临床、多层螺旋CT影像学资料,结合CT血管造影(computed tomography angiography,CTA)、多平面图像重组和二维曲面重组等影像技术观察其影像学表现,分析影像学表现与病理结果的相关性。结果 30例胰腺导管内乳头状黏液性肿瘤的多层螺旋CT诊断:主胰管型13例,分支胰管型9例,混合型8例;术后病理结果显示胰腺导管内乳头状黏液性瘤8例,胰腺交界性或低度恶性乳头状黏液瘤8例,胰腺导管内乳头状黏液癌14例。结论胰腺导管内乳头状黏液性肿瘤具有特征性的影像学表现,螺旋CT能协助诊断并能对其分型,运用CTA、多平面图像重组和二维曲面重组等影像技术有助于术前评估肿瘤的良、恶性。     

胰腺导管内乳头状黏液性肿瘤的影像学分析

目的:探讨胰腺导管内乳头状黏液性肿瘤(intraductal papillary mucinous neoplasm,IPMN)的CT和磁共振成像(mag-netic resonance imaging,MRI)影像学表现。方法:回顾性分析经手术病理证实的18例胰腺导管内乳头状黏液性肿瘤的影像资料与病理诊断。结果:主胰管型IPMN 3例,表现为主胰管扩张;分支胰管型IPMN 5例,表现为分叶状单发囊性病变或葡萄串样多发囊性病变伴腔内分隔;混合型IPMN 10例,表现为囊性病变伴主胰管扩张。结论:CT和MRI对胰腺IPMN的诊断具有重要价值。     

CT virtual pancreatoscopy: a new method for diagnosing intraductal papillary mucinous neoplasm (IPMN) of the pancreas

Background We sought to validate computed tomographic virtual pancreatoscopy (CT-VP) created by multidetector row CT (MD-CT) in the clinical diagnosis of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Methods Five cases of pancreatic IPMNs were included in this study. A nasopancreatic drainage tube was inserted and the pancreatic duct was filled with contrast medium, after which an upper abdominal scan was performed by MD-CT. CT-VP and three-dimensional (3D) CT pancreatographic images were created using a workstation and compared with images by conventional diagnostic techniques. All cases were evaluated by endoscopic retrograde pancreatography (ERP) and three cases of main duct type were assessed by intraoperative real pancreatoscopy (RP). Results In the main duct cases, papillary projections in the main pancreatic duct and branch orifices were clearly detected by CT-VP. These lesions and structures were confirmed by intraoperative RP, and the CT-VP images were clearer than RP images. In branch cases, a surface-rendering method allowed protruding lesions to be clearly detected in the dilated branches. Conclusion Compared with conventional ERP or RP, CT-VP and 3D-CT pancreatographic images were finer in quality, and the procedures were less invasive, faster, and less expensive. The potential shown by CT-VP with 3D-CT pancreatography in the clinical diagnosis of pancreatic IPMNs suggests that this approach may replace ERP in the near future.     

胰腺导管内乳头状黏液性肿瘤的声像图分析

目的 分析胰腺导管内乳头状黏液性肿瘤的临床及声像图特点,探讨经腹超声对本病的应用价值.方法 回顾性分析12例经手术病理证实的胰腺导管内乳头状黏液性肿瘤的病例资料,其中黏液腺瘤4例,黏液腺癌8例.依据病灶发生部位将其分为三种类型:主胰管型、分支胰管型和混合型,对照组织病理学结果总结其临床及声像图表现.结果 恶性者中临床症状较重,5例伴有糖尿病,2例有脂肪泻表现,4例伴有CA19-9升高,而良性者仅表现为上腹不适、腹痛等.超声显示病灶呈囊性或囊实性,良性病灶平均(1.4±0.8)cm,主胰管平均直径(1.0±0.8)cm,其中分支导管型3例(75%),主胰管型1例(25%);2例可见附壁结节,未见明确血流信号.恶性病灶平均(6.3±6.0)cm,主胰管平均直径(1.6±1.0)cm主胰管型5例(62.5%),混合型3例(37.5%),未见分支导管型;7例(7/8,87.5%)可见附壁结节,5例结节内测及较丰富的血流信号.结论 经腹超声可显示胰腺导管内乳头状黏液性肿瘤的病变特点,即囊性或囊实性病灶及扩张的胰管,结合患者的临床症状及超声所显示的病灶大小、结构及血流信号等可进一步提示其良恶性.     

Mucinous cystadenomas and intraductal papillary mucinous tumors of the pancreas in magnetic resonance cholangiopancreatography

BACKGROUND AND STUDY AIMS: In mucin-producing tumors of the pancreas, diagnosis using endoscopic retrograde cholangiopancreatography (ERCP) is limited to cystic formations that communicate with the main pancreatic duct. Magnetic resonance cholangiopancreatography (MRCP) is a new, sophisticated method which is currently under evaluation. The authors describe the usefulness of MRCP in diagnosis of mucin-producing tumors. PATIENTS AND METHODS: Six patients with mucin-producing tumors were investigated using MRCP and ERCP. Imaging was compared with surgery and histopathological examinations. RESULTS: Three patients were found to have mucinous cystadenomas (MC), two patients had intraductal papillary mucinous tumors (IPMT) and one patient had a cystadenocarcinoma. MRCP demonstrated the cystic formations in all patients. Magnetic resonance imaging (MRI) showed contrast-mediated enhancement of the cystic wall in patients with MC, and visualized the pancreatic ducts completely in patients with IPMT. ERCP failed to visualize the cystic lesion in one patient with MC of the pancreatic tail. Furthermore, ERCP showed evidence of IPMT in dilated main ducts with multiple filling defects but did not visualize the ducts completely. CONCLUSIONS: MRCP provides visualization of pancreatic ducts, extraductal variations, and cystic formations more completely than ERCP does. It avoids complications seen in ERCP. MRCP may replace ERCP in the evaluation of mucin-producing tumors of the pancreas.     

Biliary parasitic diseases including clonorchiasis,opisthorchiasis and fascioliasis

Parasitic infection of the biliary tree is caused by liver flukes, namely Clonorchis sinensis and Opisthorchis viverrini. These flukes reside in the peripheral small bile ducts of the liver and produce chronic inflammation of the bile duct, bile duct dilatation, mechanical obstruction, and bile duct wall thickening. On imaging, peripheral small intrahepatic bile ducts are dilated, but the large bile ducts and extrahepatic bile ducts are not dilated or slightly dilated. There is no visible caused of obstruction. Sometimes, in heavy infection, adult flukes are demonstrated on sonography, CT or MR cholangiography as small intraluminal lesions. The flukes in the gallbladder may appear as floating, small objects on sonography. Chronic infection may result in cholangiocarcinoma of the liver parenchyma or along the bile ducts. Human infection of Fasciola hepatica, a cattle flukes, may occur inadvertently, and the flukes migrate in the liver (hepatic phase) and reside the bile ducts (biliary phase). Image findings in the hepatic phase present with multiple, small, clustered, necrotic cavities or abscesses in the peripheral parts of the liver, showing “tunnels and caves” sign, reflecting parasite migration in the liver parenchyma. In the biliary phase, the flukes are demonstrated in the intra- and extrahepatic bile ducts and the gallbladder as small intraluminal flat objects, sometimes moving spontaneously. Bile ducts are dilated.     

Co-occurrence of IPMN and malignant IPNB complicated by a pancreatobiliary fistula: A case report and review of the literature

BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB) is pathologically similar to intraductal papillary mucinous neoplasm(IPMN). However, there are several significant differences between them. The rate of IPMN associated with extrapancreatic malignancies has been reported to range from 10%-40%, and it may occasionally be complicated with the presence of fistulas. IPMN associated with malignant IPNB is extremely rare and only nine cases have been reported in the literature.CASE SUMMARY We report a 52-year-old man who presented with recurrent cholangitis for nine months. Computed tomography and magnetic resonance cholangiopancreatography showed the common bile duct stricture with dilated pancreatobiliary duct without other abnormal findings. The underlying pathogenesis could not be identified based on the radiologic images. Endoscopic retrograde cholangiopancreatography revealed a pancreatobiliary fistula with dilated main pancreatic duct, biliary stricture with dilated biliary tree, and mucus discharge from the enlarged orifice of the major papilla. The patient underwent SpyGlass cholangiopancreatoscopy due to a suspected mucin-producing biliary neoplasm and indeterminate main pancreatic duct dilatation. Multiple papillary growing neoplasms with vascular images, with the extent of lesions spreading in the biliopancreatic ductal lumens, were identified by SpyGlass. In addition, the presence of a pancreatobiliary fistula was also identified. The patient was diagnosed as having benign IPMN and malignant IPNB with focal invasion by postoperative pathology. Furthermore, varying histological subtypes were present in both IPMN and IPNB. Pylorus-preserving pancreaticoduodenectomy was performed on the patient with excellent results during the 52 month followup period.CONCLUSION We deemed that pancreatography and SpyGlass allowed for an efficient diagnosis of IPMN with pancreatobiliary fistula, whereas the etiology could not be identified by radiologic imaging.     

内镜超声检查对胰腺黏液性囊性肿瘤和导管内乳头状黏液性瘤的诊断价值

目的：评价内镜超声检查（EUS）在胰腺黏液性囊性肿瘤（MCN）和导管内乳头状黏液性瘤（IPMN）及其良恶性鉴别中的价值。方法：回顾分析1998年1月至2007年12月本院经手术病理证实为胰腺黏液性肿瘤患者的EUS影像资料，其中IPMN11例，MCN10例。比较IPMN与MCN的内镜及EUS声像图特征，探讨鉴别MCN、IPMN及其良、恶性的EUS声像图指标。结果：IPMN与MCN患者间肿瘤部位、大小、主胰管直径、十二指肠主乳头开口扩张和黏液流出、肿瘤与主胰管交通等指标的差异有统计学意义（P〈0．05）。肿瘤浸润性生长是判断恶性IPMN与MCN的可靠指标。恶性IPMN主胰管直径大于良性／交界性IPMN[（12．2±3．5）mm比（6．8±2．2）mm，P=-0．011]；恶性IPMN壁结节高度大于良性，交界性IPMN（6．8±1．8）mm比（2．8±1．1）mm，P=0．001]。以主胰管直径≥11．0mm为标准，诊断恶性IPMN，其灵敏度为75％，特异度为100％；以壁结节高度／〉4．3mm为标准，则灵敏度为100％，特异度为100％。恶性MCN囊壁厚度大于良性，交界性MCN[（3．4±0．8）mm比（1．6±1．0）mm，P=-0．0281，恶性MCN壁结节高度大于良性／交界性MCN[（15．9±5．2）mm比（5．0±3．7）mm，P=-0．025]。以囊壁厚度≥2．4mm为标准诊断恶性MCN，灵敏度为100％，特异度为100％；以壁结节高度≥8．9mm为标准，则灵敏度为87．5％，特异度为100％。结论：EUS可用于鉴别IPMN与MCN，并评估肿瘤的良、恶性。     

胰腺导管内乳头状黏液性肿瘤的MSCT征象

目的探讨胰腺导管内乳头状黏液性肿瘤(IPMN)的MSCT特点。方法回顾性分析27例经病理证实的IPMN的MSCT表现。所有患者均接受16层或64层CT平扫及增强检查,其中7例接受ERCP检查。结果27例IPMN中,主胰管型11例,包括2例交界性肿瘤,4例原位癌,5例腺癌;CT表现为胰腺不同程度萎缩,主胰管扩张,8例内部可见壁结节,1例见多发斑块状钙化。分支胰管型9例,包括腺瘤和交界性肿瘤各3例,1例原位癌,2例腺癌;其中7例位于胰头部,表现为与主胰管相通的囊性病灶,内见分隔和乳头状壁结节,呈"葡萄串"样,1例可见点状钙化;2例位于胰尾部,呈类圆形囊性病灶,增强无强化。混合型7例,包括交界性肿瘤和腺癌各3例,原位癌1例,表现为主胰管及分支胰管扩张伴腔内壁结节,3例病变内可见不同程度钙化。7例接受ERCP,其中5例明确显示囊性病灶与主胰管相通。结论 IPMN的MSCT表现具有一定特征。MSCT结合ERCP检查有助于术前准确诊断。     

自身免疫性胰腺炎的CT诊断

目的 探讨自身免疫性胰腺炎(ALP)的CT表现.方法 回顾性分析6例AIP患者的临床资料,5例行螺旋CT平扫 增强扫描,其中3例患者行CT延迟扫描,其中的1例患者与另1例患者行PET/CT检查;从胰腺形态、大小、强化形式、胰管、胆总管、胰周及腹膜后间隙分析CT表现.结果 66.7%(4/6例)AIP表现为胰腺弥漫增大,33.3%(2/6例)表现为胰腺局限性增大;66.7%(4/6例)可见"鞘膜"征;100%(5/5例)增强扫描呈门脉期和延迟期均匀强化;100%(6/6例)有主胰管狭窄;33.3%(2/6例)可见胆总管胰头段狭窄致低位胆道梗阻;33.3%(2/6例)伴淋巴结肿大.2例(100%)PET/CT提示病变摄取增高.结论 自身免疫性胰腺炎具有典型的CT表现,能够明确诊断,避免不必要的手术.动脉期、门脉期及延迟期增强CT扫描对其诊断具有重要价值.     

肝内胆管乳头状瘤的CT及MR表现

目的：探讨肝内胆管乳头状瘤（Intrahepatic biliary papillomatosis,IHBP）的临床病理特征、影像学表现。方法 ：回顾性分析5例经手术病理证实的IHBP患者的临床病理特征及影像学表现,并结合文献进行分析和讨论。结果：5例IHBP患者中2例表现为间歇性黄疸、1例腹痛伴发热、1例左腰背部酸痛,1例体检时发现。影像学特点：5例均发现全胆管树系统扩张,胆总管下段无明确占位或结石,受累肝内胆管相对比另一肝叶胆管或胆总管不成比例的扩张,受累肝内胆管呈＂瘤样＂扩张,扩张的肝内胆管出现乳头状或长条状肿块影,MRCP示扩张胆管内多发乳头状及条状充盈缺损,3例位于右肝内胆管、2例位于左肝内胆管,肿块直径约0.3~2.5 cm,于CT平扫呈等或稍低密度,MR T1WI表现为等或稍低信号,T2WI上多呈等高信号,DWI上呈乳头状及条状高信号,增强扫描肿块呈轻度强化。结论：IHBP的影像学表现有一定的特征性,尤其MRCP、DWI及动态增强检查,熟悉该病的特征性影像学表现有助于对IHBP诊断及鉴别诊断。     

Imaging features of the less common pancreatic masses

Contrast-enhanced multiphase CT and dynamic gadolinium-enhanced MR have been validated in the literature as outstanding modalities for the evaluation of pancreatic pathology. In addition to the more frequently seen pancreatic adenocarcinoma, neuroendocrine tumors of the pancreas and cystic lesions such as serous and mucinous cystadenomas and IPMNs, a variety of benign and malignant lesions may occur in the pancreas. The purpose of this pictorial essay is to review the imaging findings of a variety of uncommon, benign and malignant, pancreatic neoplasms.     

胰岛素瘤的MSCT和MRI特征

目的 探讨胰岛素瘤的MSCT和MRI特征,提高对该肿瘤的定位和定性诊断能力.方法 回顾性分析经手术病理证实的18例胰岛素瘤患者的影像学资料,对12例行CT检查,1例仅行CT平扫,7例仅行三期动态增强扫描,4例同时行平扫和增强检查;16例行MR检查,其中4例同时行三期动态增强扫描;9例同时行CT和MR检查.结果 18例均为单发胰岛素瘤;8例发生在胰头(5例在钩突部),1例在胰颈,5例在胰体,4例在胰尾.CT平扫均为阴性;三期动态增强检查,11例中9例呈富血供表现,1例呈乏血供表现,1例漏诊.MR平扫肿瘤在T1WI上呈低信号,T2WI上呈等、稍高或混杂信号;4例行MR动态增强检查,均呈富血供表现.所有肿瘤边界清楚,均无血管、胰管和胆管受侵及肝转移表现.结论 胰岛素瘤有较为典型的MSCT和MRI表现,MSCT及MR检查对胰岛素瘤的定位和定性诊断有重要价值.     

MSCT后处理技术在诊断胰腺导管内乳头状黏液瘤中的应用

目的 探讨MSCT后处理技术在胰腺导管内乳头状黏液瘤(IPMN)中的诊断价值.方法 对18例经手术病理或超声内镜引导下细针穿刺证实的IPMN患者的临床、病理及MSCT检查资料进行回顾性分析,对MSCT双期增强扫描的原始数据均行MPR、MinIP及CPR,观察病变本身及其与胰管、周围结构的关系.结果 18例IPMN患者中,病变与扩张胰管相通18例(18/18,100%),胰管扩张 >1.0 cm 7例(7/18,38.89%),囊性病变17例(17/18,94.44%),囊实性病变1例(1/18,5.56%).主胰管型6例(6/18,33.33%)、分支胰管型9例(9/18,50.00%)、混合型3例(3/18,16.67%).MPR图像能清晰显示IPMN病变的大小、边界、有无强化的壁结节,也可较好显示病变与扩张胰管间的关系以及病变与周围结构之间的关系;MinIP图像在显示扩张胰管的全貌及病变与扩张胰管间关系等方面优于MPR图像及CPR图像;CPR图像有助于显示主胰管扩张的全貌.结论 利用MSCT多种后处理技术可整体显示病变、扩张胰管以及周围结构,在IPMN诊断方面具有重要价值.     

胰腺常见囊性肿瘤的影像表现特征及其鉴别诊断

目的 探讨胰腺常见囊性肿瘤的MSCT和MRI表现特征及其鉴别诊断要点。 方法 回顾性分析经手术病理证实的41例胰腺囊性肿瘤 的MSCT和MRI表现。 结果 SCN中浆液性微囊性腺瘤7例,呈分叶状,囊小而多,多具有中心瘢痕;浆液性寡囊性腺瘤2例,1例单房、1例多房,囊大而少,边缘分叶;实性浆液性腺瘤1例,CT增强检查明显强化,但T2WI可显示其囊性特征。MCN囊大而少,边缘多光滑。IPMN与胰管相通,单房者多表现为杵状指样的囊,多房者囊常呈多种形态。IPMN胰管可出现远端、近端或全程扩张,而SCN和MCN仅近端扩张。 结论 胰腺常见囊性肿瘤中囊的不同形态对鉴别诊断有提示作用。全程或远端胰管扩张只见于IPMN。     

增强CT联合纹理分析对于胰腺导管内乳头状黏液性肿瘤恶性潜能的预测价值

目的:探讨增强CT图像的纹理分析对胰腺导管内乳头状黏液性肿瘤(Intraductal papillary mucinous neoplasm,IPMN)恶性潜能的预测价值.方法:回顾性收集2010年1月-2019年12月经手术病理证实为分支胰管型IPMN(Branch duct IPMN,BD-IPMN)或混合型IPM...     

三维超声成像在胆道梗阻性疾病中的应用

目的：评价三维超声成像在胆道梗阻性疾病中的临床应用价值。方法：29例梗阻性黄疸患者在常规二维超声检查后进行三维超声检查，三维超声重建图像与二维超声图像对比，确定是否可以获得更多的诊断信息。结果：所有患者可以准确地显示梗阻水平，三维最小透明模式可清晰地显示扩张的胆管树结构，包括肝内胆管、肝总管、胆囊以及胆总管。三维最小透明模式与X线模式组合，可显示扩张的胆管与病变组织的空间位置关系。结论：三维超声重建可以更客观地显示胆管解剖，能够提供较二维超声更丰富的信息，对明确诊断及确定治疗方案有重要的临床意义。